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PROOF OF INSURANCE (2025)ACCORDCERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) 02/05/2024 TH IS ERTI !GATE 15 ISSUED AS ATTER OF INFORMATION ONLY D CONFERS NO RIGHTS P N THE CERT FIC T D R. IS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER, IMPORTANT'. If the certificate holder Is an ADDITIONAL INSURED, the po loy(fes) must have ADDITIONAL IN provisions or be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rI hts to the certificate holder in lieu of such endorsements . PRODUCER CONTACT NAME: MM - Fitness Instructors K&K Insurance Group, Inc. PHURE 1-800-506�856 NC1-260-459-5502 AIc 1712 Magnavox Way *r F- ` , Np ll Fort Wayne, IN 46804 ADDRESS: infol"atnessinsuranceµkk.com CUSTOMER 10: INSURER(S) AFFORDING COVERAGE NAIC N INSURED INSURER A: Markel Insurance Company 38970 Carmen OSterling INSURER B: 3617 Pine Ave INSURER C: Manhattan Beach, CA 90266 A Member of the Sports, Leisure & Entertainment RPG INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 000058387 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLY TYPE OF INSURANCE L ri POLICY NUMBER OF POLICY LIMITS LTR 1NSD WVD MMID MMlDO A X COMMERCIAL GENERAL LIABILITY X MIRPGOGO0000131600 04/01/2024 D4AM/2025 EACH OCCURRENCE $1,000,000 CLAIMS- OCCUR 12:01 AM EDT 12111 AM rT0 N —' MADE 1XI PREMISES Ea Occurrence $1,000,000 MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OPAGG $1,000,000 RO- F_�LOC POLICY ❑ ECT PROFESSIONAL LIABILITY $1,000,000 OTHER: PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITYCOMMO-0IN L IM Ea accident ANYAUTO BODILY INJURY (Per person) OWNED AUTOS ONLY SCHEDULED AUTOS BODILY INJURY (Per accident) HIRED NON -OWNED V A A AUTOS ONLY AUTOS ONLY Peraccident NOT PROVIDED WHILE IN HAWAII UMBRFilAL1A6 OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS -MADE AGGREGATE DIEDF7 RETENTION WORKERS COMPENSATION AND NIA EMPLOYERS' LIABILI Y ANY PROPRIETORIPARTNERI Y I N EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) El STATUTEu OTHER E.L. EACH ACCIDENT E.L. DISEASE -EA EMPLOYEE If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Certified instructor of: ZUMBA Exercise The Certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. City of Ell Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIE§ RE CANCELLED BEFORE 350 Main S1 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ei Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE Coverage is only extended to U.S. events and activities. NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas ACORD 25 (201W03) O 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: M1 RPG000000O131600 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person .s Or Or an City of El Segundo 350 Main St El Segundo, CA 90245 Named Insured: Carmen Osterling Information reauired to complete this Schedule. if not shown above. will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organizations) shown in the Schedule, but only with respect to liability for 'bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. in the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of insurance shown in the Declarations. CG 20 26 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: {__) I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of El Segundo. Policy No. L) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # (X0 I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisions or the agreement will automatically become void. Signature of Applicant Carmen Osterling Date 2/5/2024 Print Name Carmen Osterlin Agreement for: Y Dated: d-)Li Reviewed by: [ NRTM-4-_